Abstract

Background: We aim to assess the effectiveness of integrating follow shot video of real cases into Case Based Learning (CBL) during general surgery clerkship.

Materials and Methods: For representative cases, we took the follow shot of all the process from patient's admission to discharge. 76 students were randomly divided into experimental group and control group. Experimental group took CBL with follow shot video and control group took CBL only. After the teaching session, students filled designed questionnaire.

Results: Compared with the control group, experimental group show improved interest, faster reception of the theories, improved clinical thinking and analysis abilities, better doctor-patient communication, etc.

Keywords

Case based learning, Follow shot, General surgery, Clinical clerkship

Introduction

Clinical clerkship is an integral part of medical education. On
one hand, it improves the effectiveness of teaching theories in
the classroom; on the other, it facilitates the smooth transition
to the subsequent residency training. Clinical clerkship widely
uses the Case Based Learning (CBL) teaching approach, which
dissects the clinical cases representing particular areas of the
curriculum based on the principles of problem-based learning.
As a common teaching approach of the bridging stage of
medical education, CBL could be traced back to the end of the
19th century. The landmark is the first collection of
management cases by Malvin in 1921. It was initiated by
Harvard business school and carried out in the form of group
discussion on select cases. This was adopted by medical
education in 1980s [1]. Shifting the teaching environment from
classrooms to hospitals, CBL requires students to solve real
problems by using acquired textbook knowledge and through
group discussion on prepared clinical cases. In addition,
students widen their horizon and gain the cutting-edge
knowledge in the field through conducting research and
reviewing literature. The main components of this teaching
method include: 1) the instructor selects typical cases based on
the syllabus and content of the course and arranges the clinical
visits; 2) the instructor facilitates the group discussion on the
diagnosis and treatment plan based on the information obtained
through clinical visits and literature review; 3) the instructor
summarizes the discussion and conclusion, and provides advice
on further improvement. This teaching method combines the theories and real cases, transforming teaching from
“monotonous instruction” to "interactive discussion,” and
therefore improving the overall effectiveness of teaching [2-4].

As the fundamental subject of the surgery system, general
surgery deals with a variety of diseases, complex diagnosis,
and severe illness, this typically involves high risks. How to
effectively transfer the knowledge and skills to students
remains a challenge in the Department of Surgery. With our
CBL teaching experiences of many years, we find the
shortcomings of combining CBL teaching with real clinical
situations. Feedbacks from students include the difficulty of
gaining a holistic understanding of certain diseases and the
fragmentation of learning physiological and pathological
processes. During our teaching session in 2015, we edited
episodes of TV series that represent characteristics of certain
diseases in order to facilitate students’ recognition of certain
illness's characteristics, and unexpectedly found students
showed keen interest and passion in the group discussion. The
discussion even extended to outside of classroom. These TV
series were produced for general audience of little medical
knowledge, not specifically for medical trainees. We wondered
whether CBL plus the follow shot from a physician’s
perspectives could achieve a better outcome than the traditional
CBL.

To that end, we selected typical medical cases and follow shot
videos from the patient's admission to discharge from the
hospital. The videos were edited, denoted, and subtitled. We
recapitulated the key knowledge related to the disease, explained the rationale for the treatment, and recorded the
whole surgical procedures. The edited video was played after
students’ ward visits and before the group discussion. The
outcome was analysed and evaluated.

Subjects and Methods

Subjects

76 undergraduate medical students who entered Xiangya
Medical School of Central South University in 2012 for
general surgery clerkship were recruited and randomized into 2
groups. 38 subjects were included in the experimental group
and the rest 38 subjects in the control group (Table 1).

Representative cases were selected from the wards and
discussion items were created according to the curriculum and
course syllabus. For each case, medical history was recorded
and physical examination was performed by students under
supervision. Students in the control group received traditional
CBL teaching. Students were encouraged to propose diagnosis
and treatment plan, which were commented and rectified by
the instructor as necessary. Students in the experimental group
watched the prepared video made of follow shot cases and
discussed the raised questions as diagnosis proceeded.

Teaching contents and preparation

The topics covered in this study are common diseases in
general surgery, with Surgery (edited by Xiaoping and
published by Renwei Press) as the textbook. Cases included in
this study are “liver diseases”, “biliary diseases” and “portal
hypertension”. Students in both control and experimental
groups were led by the same experienced instructor from the
Department of Surgery.

The instructor prepared the teaching materials according to the
course syllabus and wrote the script for the follow shot video.
The follow shot video comprises three parts: 1) the primary
care physician collected medical history and performed
physical examination in the outpatient/emergency department;
2) the attending physician collected detailed medical history,
performed additional physical examination, and facilitated the
process and interpretation of supplemental examinations; 3) the
discussion of treatment plan with patients, treatment and
rehabilitation. With written consent from patients,
representative cases were follow shot by the course instructor
and a photographer. After patients were admitted, the attending
physician started to get involved in the follow video shot. Prior
to the medical history inquiry and physical examination, the
attending physician was recapitulated with the key knowledge
that was supposed to be highlighted in teaching. The process of
medical encounter, including consultation, was videotaped. All
the examination results were recorded and compiled. With all
the available information, the attending physician analysed the
patient's case, proposed and discussed treatment plans with the
patient. After the treatment plan confirmed, the process of medical intervention or surgery, recovery from the procedures
and discharge was completed and recorded. After all the follow
shots, videotapes were edited by a professional videography
editor. Subtitles and pertinent explanation were added, to
improve the instructive quality of the video.

Implementation of the teaching method

Control group: Students in the control group were taught with
the traditional CBL teaching method. Briefly, instructors
specified the teaching contents and students prepared lessons
prior to classes. The instructor selected representative clinical
cases and instructed students to collect medical history and to
perform physical examination under supervision. Further
medical information was gathered from the patient's previous
medical record. In the classroom, students reported collected
information and discussed diagnosis, staging, and treatment
plan for each case, with the instructor's facilitation. Questions
included: “are the symptoms consistent with the CT data?”
“What characteristics of contrast medium at different stages
should be considered when interpreting CT data?” “How to
choose the appropriate biliary tract angiography?” “The
mechanism and progress of Terlipressinum decreasing portal
hypertension,” etc. The key points related to these questions
were provided to students after the group discussion. The
instructor led the discussion with special attentions to the
relevance of the discussion with the cases, the scope and
direction of the discussion. Students were encouraged to search
relevant online information about the discussion after class.
The instructor helped students to learn knowledge and skills
through evaluating the patient reports and students’ critical
thinking ability, and through summarizing diagnosis and
treatment with reference to the textbook knowledge.

Experimental group: Prior to the group discussion, students
in the experimental group went through the same process as
those in the control group. At the beginning of the discussion,
the follow shot video was played. The video included three
parts and group discussion was carried out after each part. The
first part covered the whole process of collecting medical
history and observing symptoms. Through watching this part
of video, students were taught how to acquire information
about certain diseases, what were the possible diagnosis and
potential treatment strategy, what supplemental examinations
were required, whether emergency treatment was needed-all of
these questions are necessary to be considered in the
emergency department. The instructor encouraged students to
pay attention to the attending physician’s questions and
physical examination, and explained the reasons of doing
things that way. Students were also encouraged to appreciate
the humanity side of patients. The second part of the video was
the major part of theories and knowledge that were highlighted
by the instructor when preparing the script. In this part, the
patient disclosed chief complaint and its progress, and recalled
details prior to the incident. The patient also reported previous
interventions and effectiveness, familial history of diseases, as
well as positive and negative signs. The supplemental
examinations were included. For specific examinations such as
CT or angiography, prerequisite training was completed by all students. This part of video contained the major topics for the
group discussion. Students were prompted to independently
propose diagnosis and reasoning based on the medical history,
physical examination, and with the results from supplemental
examinations. Students further analysed the pathological
aspects of the cases. In the third part of the video, students
compared their diagnosis and treatment plans with each other
and discussed the pros and cons of strategies. Students watched
the process of medical consultation and how to obtain
informed consent. By understanding the process, students
learned the key information that the attending physician
delivered to the patient and practiced this process by simulated
scenarios. The instructor further explained the preparation,
planning, and process of surgical procedures.

Assessment of the teaching methods

Questionnaires: After the course, all student participants were
surveyed by a specifically designed questionnaire. 38
questionnaires were distributed to the experimental group and
38 collected, with a recovery rate of 100%; 38 questionnaires
were distributed to the control group and 38 collected, with a
recovery rate of 100%. The questionnaire used a score scale of
0 to 9, with 0 being the worst and 9 the best. Students were
asked to provide their genuine thoughts on their experience in
the class. Questions included: 1) to what degree this course
stimulated your study interest; 2) to what degree the teaching
method helped you understand textbook knowledge; 3) to what
extent this teaching exercised your clinical thinking ability; 4)
how helpful was the teaching for your analysing skills; 5) how
helpful was the teaching for your communication with your
patients; 6) how helpful was this teaching prepare you for your
clinical tasks; 7) to what extent this teaching helped your teamwork
capacity; 8) what score would you assign to this course;
9) how much this course contributed to your future choice to
enter general surgery specialty.

Statistical analysis

All data were analysed by using the SPSS 19.0 software
package. Mann-Whitney U test was used to compare data from
experimental and control groups. A p<0.05 was considered to
be statistically significant.

Discussions

CBL is the main teaching method used in the clinical clerkship
in the Department of Surgery in our medical school. Although
it has been practiced and constantly improved for years, the
effectiveness remains less than optimal. 1) Authenticity:
although all cases for teaching purpose are derived from the
ward, instructors intentionally create representative cases
perfectly matching curriculum. The teaching process is
successfully achieved, but students’ classroom experiences are
somehow different from the real cases [5]; 2)
Representativeness As some medical cases are rare, the ward
doesn’t always have all representative cases available for the
teaching purpose, which might negatively affect the quality
and consistency of teaching; 3) Completeness It is simply
unrealistic for students to gain clinical diagnosis experiences
on all cases in 4 studying hours. Videos and pictures are
typically used to achieve the teaching goal, but the
fragmentation of information on medical cases is not always
helpful for students to appreciate the case from a holistic
perspective; 4) Instructiveness follow shot videos plus group
discussion could provide students with simulated experiences
of real situations, helping students absorb knowledge faster and
apply skills to real cases better.

In addition, there are two realistic problems to consider. First,
due to the considerable tension built up between physicians
and patients in Mainland China, some patients tend to repel
junior medical trainees and refuse cooperation with them, even
in the presence of the attending physician. This leads to mental
stress of trainees and results in their extra cautiousness in the
medical encounter. Second, for years instructors and students
unintentionally pay great attention to the technical side of
practicing medicine and ignore the psychosocial side of
patients during the medical training; we believe that much
more emphasis should be given to treating patients as
individuals of wholesome, and communication skills are
therefore crucial for medical practice.

How to effectively improve the CBL remains our priority. We
tried to follow shot cases and presented the edited video to 2012 medical undergraduate trainees. We found this method
could complement the current CBL teaching by providing real
cases in its whole and presenting to students with full
information. Students were able to apply knowledge and skills
systematically and solve the real problems in the daily practice.
In addition, the video fully displayed all the tasks that the
attending physician carried out, including analysis of the case,
communication and consultation with patients. This
information is not readily found in the textbook and through
shadowing physicians occasionally.

We found the experimental group showed higher participation
rate and created more positive discussion atmosphere. In the
first eight questions we asked, responses from the experimental
group are significantly better than the control group. For the
9th question, no significant difference was observed between
groups, which are consistent with our practical experience that
students typically already have their career plan in mind prior
to clinical clerkship and that is minimally influenced by the
course.

Interestingly, students showed great interest in the group
discussion and actively exchanged their thoughts on the
medical history and examination results. According to them,
the greatest reward of this learning was how to
comprehensively gain medical information with key
knowledge points in mind. In the follow shot video, the most
interesting aspect to students was the supplemental
examinations, which were used to confirm their initial
diagnosis, strengthen their understanding of textbook
knowledge, and improve their critical thinking and clinical
reasoning skills [6,7]. Students also gained understanding on
the supplemental examinations that was not covered in the
textbook and only experienced by the attending or resident
physicians. In addition, the instructor further led students to
analyse the pathology, to critically evaluate the consistency
between diagnosis and medical history/signs, and to assess the
validity of diagnosis with supplemental examination results. As
the discussion proceeded, students were encouraged to search
additional online literature and continue exercise discussion. In
general, students felt that the learning was of fast pace, high
efficiency, and large amount of information. In addition, CBL
was found to be effective and popular among continuing
education and learning cutting-edge knowledge [8].

When discussing the communication and consultation process,
students were invited to play the roles of physicians and
patients so that students could gain perspectives of both sides.
Students showed strong interest in this teaching method of
simulated scenarios and reported a better comprehension on the
medical encounter. Due to the nature of medicine, there is a
clear trend of valuing technical skills over other aspects. We,
however, believe that communication skills are as important as
technical skills in practicing medicine. Studies show that
general surgery is among the top three specialties with high
rate of medical disputes, and 11.7% of medical disputes are
due to miscommunication. Therefore, it is critical to teach
students how to effectively communicate with their patients, in order to train future physicians of excellent competency and to
better serve the society [9].

Limitations

CBL supplemented with the follow shot video achieves better
outcomes than the traditional ward visits in clinical clerkship.
According to our literature review, follow shot video has not
been used by any medical educational institution so far. The
outcome of our study shows the advantage of this teaching
approach, but further improvement is warranted. During the
implementation, we noticed a few areas to improve upon. In
order to improve the quality of the teaching material, we will
collaborate with professional cameramen and video editors in
videography and editing processes to better emphasize the key
points and to make the video more visually appealing. In
addition, with the complexity of medical cases in mind, it will
take significant amount of time and effort to collect videos
covering a range of cases. As the first trial of follow shot video
as the supplemental material for CBL, further improvement
upon designing the questionnaire is also warranted.